private duty nursing for children billing guide · 7/17/2020 · subject change reason for change...
TRANSCRIPT
Washington Apple Health (Medicaid)
Private Duty
Nursing for
Children Billing
Guide
July 17, 2020
2 | PRIVATE DUTY NURSING FOR CHILDREN BILLING GUIDE
Disclaimer Every effort has been made to ensure this guide’s accuracy. If an actual or
apparent conflict between this document and an HCA rule arises, HCA rules
apply.
Billing guides are updated on a regular basis. Due to the nature of content
change on the internet, we do not fix broken links in past guides. If you find a
broken link, please check the most recent version of the guide. If this is the most
recent guide, please notify us at [email protected].
About this guide* This publication takes effect July 17, 2020, and supersedes earlier billing guides
to this program.
The Health Care Authority is committed to providing equal access to our services.
If you need an accommodation or require documents in another format, please
call 1-800-562-3022. People who have hearing or speech disabilities, please call
711 for relay services.
Washington Apple Health means the public health insurance
programs for eligible Washington residents. Washington Apple
Health is the name used in Washington State for Medicaid, the
children’s health insurance program (CHIP), and state-only
funded health care programs. Washington Apple Health is
administered by the Washington State Health Care Authority.
Refer also to HCA’s ProviderOne billing and resource guide for valuable
information to help you conduct business with the Health Care Authority.
How can I get HCA Apple Health provider documents? To access providers alerts, go to HCA’s provider alerts webpage.
To access provider documents, go to HCA’s provider billing guides and fee
schedules webpage.
Where can I download HCA forms? To download an HCA form, see HCA’s Forms & Publications webpage. Type only
the form number into the Search box (Example: 13-835).
* This publication is a billing instruction.
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Copyright disclosure Current Procedural Terminology (CPT) copyright 2019 American Medical
Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Fee schedules, relative value units, conversion factors and/or related components
are not assigned by the AMA, are not part of CPT, and the AMA is not
recommending their use. The AMA does not directly or indirectly practice
medicine or dispense medical services. The AMA assumes no liability for data
contained or not contained herein.
What has changed?
Subject Change Reason for Change
Coverage Table Effective for dates of
service on and after
March 1, 2020, until
further notice, two
temporary add-on
codes with a CR
modifier are
approved for private
duty nursing. Added
a link to the PDN
information about
the two temporary
add-on codes.
These temporary add-on
codes are for designated
dates during the COVID-
19 pandemic only.
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Table of Contents Available Resources ............................................................................................................................ 6
Definitions ............................................................................................................................................... 7
Private Duty Nursing Services ....................................................................................................... 8
What is the purpose of the program? ................................................................................... 8
What are private duty nursing services? .............................................................................. 8
Client Eligibility ..................................................................................................................................... 9
Who is eligible for private duty nursing services? .......................................................... 9
How do I verify a client’s eligibility? ................................................................................... 10
Verifying eligibility is a two-step process: .................................................................. 10
Are clients enrolled in an agency-contracted managed care organization
eligible? ............................................................................................................................................. 10
Managed care enrollment ................................................................................................... 11
Apple Health – Changes for January 1, 2020 ............................................................. 12
Clients who are not enrolled in an HCA-contracted managed care plan for
physical health services ........................................................................................................ 12
Integrated managed care .................................................................................................... 13
Integrated managed care regions ................................................................................... 13
Integrated Apple Health Foster Care (AHFC) ............................................................ 14
Fee-for-service Apple Health Foster Care ................................................................... 15
Provider/Client Responsibilities ................................................................................................. 16
Who performs private duty nursing services? ............................................................... 16
Who is responsible for choosing a private duty nursing agency? ....................... 16
What are the application requirements? .......................................................................... 16
Prior Authorization........................................................................................................................... 18
Is prior authorization (PA) required? .................................................................................. 18
How do I request PA? ................................................................................................................. 18
Where do I send the completed referral? ................................................................... 18
When does DDA approve requests for private duty nursing services? ............. 18
Coverage ............................................................................................................................................... 19
What is covered? .......................................................................................................................... 19
Coverage Table .................................................................................................................................. 20
Where can I find the fee schedule? ..................................................................................... 21
Billing ...................................................................................................................................................... 22
What are the general billing requirements? ................................................................... 22
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May RN and LPN service hours be performed in combination? ........................... 22
What about multiple clients in the same home? .......................................................... 22
How do I bill services covering more than one month? ........................................... 22
How do I bill claims electronically? ..................................................................................... 22
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Available Resources
Topic Contact Information
Becoming a provider or submitting a change
of address or ownership
See HCA’s Billers, providers, and partners
webpage.
Finding out about payments, denials, claims
processing, or agency-contracted managed
care organizations
See HCA’s Billers, providers, and partners
webpage.
Electronic billing See HCA’s Billers, providers, and partners
webpage.
Finding agency documents (e.g., billing
instructions, # memos, fee schedules)
See HCA’s Billers, providers, and partners
webpage.
Private insurance or third-party liability, other
than agency-contracted managed care
See HCA’s Billers, providers, and partners
webpage.
Who do I call for pharmacy authorization? See HCA’s Billers, providers, and partners
webpage.
Where do I send backup documentation? See HCA’s Billers, providers, and partners
webpage.
Who do I call for prior authorization? Developmental Disabilities Administration
(DDA)
Medically Intensive Home Care Program
Manager
(360) 407-1504
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Definitions This section defines terms and abbreviations, including acronyms, used in these
billing instructions. Refer to Chapter 182-500 WAC for a complete list of
definitions for Washington Apple Health.
Developmental Disabilities Administration (DDA) –The organization within the
Department of Social and Health Services (DSHS) that administers the Medically
Intensive Home Care Program (MICP).
Home Health Agency – An agency or organization certified under Medicare to
provide comprehensive health care on a part-time or intermittent basis to a
patient in the patient's place of residence.
Intermittent Home Health – Skilled nursing services and specialized therapies
provided in a client’s residence. Services are for clients with acute, short-term
intensive courses of treatment.
Medically Intensive Children’s Program (MICP) – A program managed by DDA
that provides a home-based program for clients age 17 and under who require
complex, long-term care for a condition of such severity and/or complexity that
continuous skilled nursing care is required. Persons with medically intensive
needs require more individual and continuous care than is available from an
intermittent visiting nurse.
Nursing Care Consultant – A registered nurse employed by DSHS to evaluate
clinical eligibility for the MICP and provide a written assessment summary.
Plan of Treatment (POT) – (Also known as “plan of care” (POC)) The written
plan of care for a patient which includes, but is not limited to, the physician's
order for treatment and visits by the disciplines involved, the certification period,
medications, and rationale indicating need for services.
Private Duty Nursing – Skilled nursing care and services provided in the home
for clients with complex medical needs that cannot be managed within the scope
of intermittent home health services.
Skilled Nursing Care – The medical care provided by a licensed nurse or
delegate working under the direction of a physician as described in RCW
18.79.260.
Skilled Nursing Services – The management and administration of skilled
nursing care requiring the specialized judgment, knowledge, and skills of a
registered nurse or licensed practical nurse as described in RCW 18.79.040 and
18.79.060.
Usual and Customary Charge – The rate that may be billed to HCA for a certain
service or equipment. This rate may not exceed either of the following:
The usual and customary charge that you bill the general public for the same
services
If the general public is not served, the rate normally offered to other
contractors for the same services
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Private Duty Nursing Services
What is the purpose of the program? Private duty nursing services are administered by the Developmental Disabilities
Administration (DDA) through the Medically Intensive Children’s Program (MICP).
The purpose of this program is to reduce the cost of health care services by
providing equally effective, more conservative, and/or less costly treatment in a
client’s home.
Private duty nursing services are considered supportive to the care provided to
the client by family members or guardians. Private duty nursing services are
decreased as the family/guardian or other caregiver becomes able to meet the
client’s needs, or when the client’s needs diminish.
What are private duty nursing services? (Refer to WAC 182-551-3000)
Private duty nursing services consist of four or more hours of continuous skilled
nursing services provided in the home to eligible clients with complex medical
needs that cannot be managed within the scope of intermittent home health
services.
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Client Eligibility Most Apple Health clients are enrolled in an HCA-contracted managed care
organization (MCO). This means that Apple Health pays a monthly premium to an
MCO for providing preventative, primary, specialty, and other health services to
Apple Health clients. Clients in managed care must see only providers who are in
their MCO’s provider network, unless prior authorized or to treat urgent or
emergency care. Providers must follow the policies and procedures of the client’s
MCO, including prior authorization of services. See HCA’s Apple Health managed
care page for further details.
It is important to always check a client’s eligibility prior to
providing any services because it affects who will pay for the
services.
Who is eligible for private duty nursing services? To be eligible for private duty nursing services under the Medically Intensive
Children’s Program (MICP), clients must meet all of the following:
Be age 17 or younger
Meet financial eligibility under the categorically needy program, the medically
needy program, or an alternative benefits plan program (see WAC 182-501-
0060)
Meet medical eligibility as follows:
o Require four or more continuous hours of active skilled nursing care with
consecutive tasks at a level that cannot be delegated at the time of the
initial assessment and can be provided safely outside of a hospital in a
less restrictive setting
o Require two or more tasks of complex skilled nursing, such as:
Systems assessments, including multistep approaches of systems
(e.g., respiratory assessment, airway assessment, vital signs,
nutritional and hydration assessment, complex gastrointestinal
assessment and management, seizure management requiring
intervention, or level of consciousness)
Administration of treatment for complex respiratory issues related to
technological dependence requiring multistep approaches on a day-
to-day basis (e.g., ventilator tracheostomy)
Assessment of complex respiratory issues and interventions with use
of oximetry, titration of oxygen, ventilator settings, humidification
systems, fluid balance, or any other cardiopulmonary critical
indicators based on medical necessity
Skilled nursing interventions of intravenous/parenteral administration
of multiple medications and nutritional substances on a continuing
or intermittent basis with frequent interventions
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Skilled nursing interventions of enteral nutrition and medications
requiring multistep approaches daily
Have informal support by a person who has been trained to provide
designated skilled nursing care and is able to perform the care as required
Have prior authorization from the Developmental Disabilities Administration
(DDA)
Have exhausted all other funding sources for private duty nursing (see RCW
74.09.185) prior to accessing these services through the MICP
How do I verify a client’s eligibility? Check the client’s services card or follow the two-step process below to verify
that a client has Apple Health coverage for the date of service and that the
client’s benefit package covers the applicable service. This helps prevent
delivering a service HCA will not pay for.
Verifying eligibility is a two-step process:
Step 1. Verify the patient’s eligibility for Apple Health. For detailed
instructions on verifying a patient’s eligibility for Apple Health,
see the Client Eligibility, Benefit Packages, and Coverage Limits
section in HCA’s ProviderOne Billing and Resource Guide.
If the patient is eligible for Apple Health, proceed to Step 2. If
the patient is not eligible, see the note box below.
Step 2. Verify service coverage under the Apple Health client’s
benefit package. To determine if the requested service is a
covered benefit under the Apple Health client’s benefit package,
see HCA’s Program Benefit Packages and Scope of Services
webpage.
Note: Patients who are not Apple Health clients may submit an application for
health care coverage in one of the following ways:
1. By visiting the Washington Healthplanfinder’s website.
2. By calling the Customer Support Center toll-free at: 855-WAFINDER
(855-923-4633) or 855-627-9604 (TTY)
3. By mailing the application to: Washington Healthplanfinder, PO Box 946,
Olympia, WA 98507
In-person application assistance is also available. To get information about in-
person application assistance available in their area, people may visit the
Washington Healthplanfinder’s website or call the Customer Support Center.
Are clients enrolled in an agency-contracted managed
care organization eligible? Yes. Private duty nursing services are included in the scope of service under
agency-contracted MCOs. For these clients, managed care enrollment will be
displayed on the client benefit inquiry screen in ProviderOne.
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All medical services covered under an MCO must be obtained by the client
through designated facilities or providers. The MCO is responsible for the
following:
Payment of covered services
Payment of services referred by a provider participating with the plan to an
outside provider
Send claims to the client’s MCO for payment. Call the client’s MCO to discuss
payment prior to providing the service. Providers may bill clients only in very
limited situations as described in WAC 182-502-0160.
Note: To prevent billing denials, please check the client’s
eligibility prior to scheduling services and at the time of the
service and make sure proper authorization or referral is
obtained from the plan. See HCA’s ProviderOne billing and
resource guide for instructions on how to verify a client’s
eligibility.
Women enrolled in the primary care case management (PCCM)
model of Healthy Options must have a referral from their PCP in
order for women’s health care services to be paid to an outside
provider. The reason for this is the Indian clinics that contract
with HCA as PCCMs do not meet the definition of health carriers
in chapter 48.42 RCW. These clinics are not any of the
organizations listed in Section 1 of this RCW; thus, they are
exempt from the requirements spelled out in this act, including
self-referrals by women to women’s health care services.
Managed care enrollment Apple Health (Medicaid) places clients into an agency-contracted MCO the same
month they are determined eligible for managed care as a new or renewing
client. This eliminates a person being placed temporarily in fee-for-service (FFS)
while they are waiting to be enrolled in an MCO or reconnected with a prior
MCO. This enrollment policy also applies to clients in FFS who have a change in
the program they are eligible for. However, some clients may still start their first
month of eligibility in the FFS program because their qualification for MC
enrollment is not established until the month following their Medicaid eligibility
determination.
New clients are those initially applying for benefits or those with changes in their
existing eligibility program that consequently make them eligible for Apple
Health managed care.
Renewing clients are those who have been enrolled with an MCO but have had a
break in enrollment and have subsequently renewed their eligibility.
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Checking eligibility
Providers must check eligibility and know when a client is enrolled and with
which MCO. For help with enrolling, clients can refer to the Washington
Healthplanfinder’s Get Help Enrolling page.
MCOs have retroactive authorization and notification policies in place. The
provider must know the MCO’s requirements and be compliant with the
MCO’s policies.
Apple Health – Changes for January 1, 2020 Effective January 1, 2020, the Health Care Authority (HCA) completed the move
to whole-person care to allow better coordination of care for both body (physical
health) and mind (mental health and substance use disorder treatment, together
known as “behavioral health”). This delivery model is called Integrated Managed
Care (formerly Fully Integrated Managed Care, or FIMC, which still displays in
ProviderOne and Siebel).
IMC is implemented in the last three regions of the state:
Great Rivers (Cowlitz, Grays Harbor, Lewis, Pacific, and Wahkiakum counties)
Salish (Clallam, Jefferson, and Kitsap counties)
Thurston-Mason (Mason and Thurston counties)
These last three regions have plan changes, with only Amerigroup, Molina, and
United Healthcare remaining. There are changes to the plans available in these
last three regions. The only plns that will be in these regions are Amerigroup,
Molina and United Healthcare. If a client is currently enrolled in one of these
three health plans, their health plan will not change.
Clients have a variety of options to change their plan:
Available to clients with a Washington Healthplanfinder account:
Go to Washington HealthPlanFinder website .
Available to all Apple Health clients:
o Visit the ProviderOne Client Portal website:
o Call Apple Health Customer Service at 1-800-562-3022. The automated
system is available 24/7.
o Request a change online at ProviderOne Contact Us (this will generate
an email to Apple Health Customer Service). Select the topic
“Enroll/Change Health Plans.”
For online information, direct clients to HCA’s Apple Health Managed Care
webpage.
Clients who are not enrolled in an HCA-contracted
managed care plan for physical health services Some Medicaid clients do not meet the qualifications for managed care
enrollment. These clients are eligible for services under the FFS Medicaid
program. In this situation, each Integrated Managed Care (IMC) plan will have
Behavioral Health Services Only (BHSO) plans available for Apple Health clients
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who are not in managed care. The BHSO covers only behavioral health treatment
for those clients. Clients who are not enrolled in an HCA-contracted managed
care plan are automatically enrolled in a BHSO with the exception of American
Indian/Alaska Native clients. Some examples of populations that may be exempt
from enrolling into a managed care plan are Medicare dual-eligible, American
Indian/Alaska Native, Adoption support and Foster Care alumni.
Integrated managed care Clients qualified for managed care enrollment and living in integrated managed
care (IMC) regions will receive all physical health services, mental health services,
and substance use disorder treatment through their HCA-contracted managed
care organization (MCO).
American Indian/Alaska Native (AI/AN) clients have two
options for Apple Health coverage:
- Apple Health Managed Care; or
- Apple Health coverage without a managed care plan (also
referred to as fee-for-service [FFS])
If a client does not choose an MCO, they will be automatically
enrolled into Apple Health FFS for all their health care services,
including comprehensive behavioral health services. See the
Health Care Authority’s (HCA) American Indian/Alaska Native
webpage.
For more information about the services available under the FFS
program, see HCA’s Mental Health Services Billing Guide and
the Substance Use Disorder Billing Guide.
For full details on integrated managed care, see HCA’s Apple Health managed
care webpage and scroll down to “Changes to Apple Health managed care.”
Integrated managed care regions Clients residing in integrated managed care regions and who are eligible for
managed care enrollment must choose an available MCO in their region. Details,
including information about mental health crisis services, are located on HCA’s
Apple Health managed care webpage.
Region Counties Effective Date
Great Rivers Cowlitz, Grays Harbor, Lewis, Pacific,
and Wahkiakum
January 1, 2020
Salish Clallam, Jefferson, and Kitsap January 1, 2020
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Region Counties Effective Date
Thurston-Mason Thurston and Mason January 1, 2020
North Sound Island, San Juan, Skagit, Snohomish,
and Whatcom
July 1, 2019
Greater Columbia Asotin, Benton, Columbia, Franklin,
Garfield, Kittitas, Walla Walla, Yakima,
and Whitman
January 1, 2019
King King January 1, 2019
Pierce Pierce January 1, 2019
Spokane Adams, Ferry, Lincoln, Pend Oreille,
Spokane, and Stevens
January 1, 2019
North Central Grant, Chelan, Douglas, and
Okanogan
January 1, 2018
January 1, 2019 (Okanogan)
Southwest Clark, Skamania, and Klickitat April 2016
January 1, 2019 (Klickitat)
Integrated Apple Health Foster Care (AHFC) Children and young adults in the Foster Care, Adoption Support and Alumni
programs who are enrolled in Coordinated Care of Washington’s (CCW) Apple
Health Foster Care program receive both medical and behavioral health services
from CCW.
Clients under this program are:
Under the age of 21 who are in foster care (out of home placement)
Under the age of 21 who are receiving adoption support
Age 18-21 years old in extended foster care
Age 18 to 26 years old who aged out of foster care on or after their 18th
birthday (alumni)
These clients are identified in ProviderOne as “Coordinated Care
Healthy Options Foster Care.”
The Apple Health Customer Services staff can answer general questions about
this program. For specific questions about Adoption Support, Foster Care or
Alumni clients, contact HCA’s Foster Care Medical Team at 1-800-562-3022, Ext.
15480.
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Fee-for-service Apple Health Foster Care Children and young adults in the fee-for-service Apple Health Foster Care,
Adoption Support and Alumni programs receive behavioral health services
through the regional Behavioral Health Services Organization (BHSO). For details,
see HCA’s Mental Health Services Billing Guide , under How do providers identify
the correct payer?
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Provider/Client Responsibilities
Who performs private duty nursing services? (Refer to WAC 182-551-3200)
Providers qualified to deliver private duty nursing services under the Medically
Intensive Children’s Program (MICP) must have all of the following:
An in-home services license with the state of Washington to provide private
duty nursing
A contract with the Developmental Disabilities Administration (DDA) to
provide private duty nursing
A signed core provider agreement with the Health Care Authority (HCA)
Appropriate medical training for the nurses and the family/guardian is the
responsibility of the discharging hospital and the receiving licensed home health
agency. Training costs due to nurse turnover or client transfers are the
responsibility of the licensed home health agency.
The licensed home health agency is responsible for meeting all of the client's
nursing needs. The Medicaid agency will not approve intermittent nursing visits
in addition to Private Duty Nursing services.
Who is responsible for choosing a private duty
nursing agency? Choosing a licensed home health agency is the responsibility of one, or a
combination, of the following caregivers involved with the client's care:
Family member/guardian
Attending physician
Client's social worker or case manager
Discharge planner
See “How do I request PA?”
What are the application requirements? (Refer to WAC 182-551-3300)
Clients requesting private duty nursing services through fee-for-service must
submit a completed and signed Medically Intensive Children’s Program (MICP)
Application form (DSHS 15-398). The MICP application must include all of the
following:
DSHS 14-012 Consent form
DSHS 14-151 Request for DDA Eligibility Determination form (for clients not
already determined DDA-eligible)
DSHS 03-387 Notice of Practices for Client Medical Information form
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Appropriate and current medical documentation including a medical plan of
treatment or plan of care (WAC 246-335-540) with the client’s age, medical
history, diagnoses, and the parent or guardian contact information including
address and phone number
A list of current treatments or treatment records
Information about ventilator, bi-level positive airway pressure (BiPAP), or
continuous positive airway pressure (CPAP) hours per day or frequency of use
History and physical examination from current hospital admission, recent
discharge summary, or recent primary physician exam
A recent interim summary, discharge summary, or clinical summary
Recent daily nursing notes within the past five to seven days of hospitalization
or in-home nursing documentation
Current nursing care plan that may include copies of current daily nursing
notes that describe nursing care activities
An emergency medical plan that includes strategies to address loss of power
to the home and environmental disasters such as methods to maintain life-
saving medical equipment supporting the client; the plan may include
notification of electric and gas companies and the local fire department.
A psycho-social history/summary with all of the following information, as
available:
o Family arrangement and current situation
o Available personal support systems
o Presence of other stresses within and upon the family
Statement that the home care plan is safe for the client and is agreed to by
the client’s parent or legal guardian.
Information about other family supports such as Medicaid, school hours, or
hours paid by a third-party insurance or trust
For a client with third-party insurance or a managed care organization (MCO),
a denial letter from the third-party insurance or MCO that states the private
duty nursing will not be covered
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Prior Authorization
Is prior authorization (PA) required? (Refer to WAC 182-551-3400)
Yes. Providers must receive prior authorization (PA) from the Developmental
Disabilities Administration (DDA) prior to providing private duty nursing services
to clients.
The Medicaid agency approves requests for private duty nursing services on a
case-by-case basis.
How do I request PA? (Refer to WAC 182-551-3400)
A provider must coordinate with a DDA case manager and request PA by
submitting a complete referral to DDA. This referral must include a complete
signed Medically Intensive Children’s Program (MICP) application form (DSHS 15-
398). See What are the application requirements?
Note: Please see HCA’s ProviderOne billing and resource guide
for more information on requesting authorization.
Where do I send the completed referral? MICP Manager
PO Box 45310
Olympia WA 98504-5310
Fax: (360) 407-0954
When does DDA approve requests for private duty
nursing services? (Refer to WAC 182-551-3400)
The Developmental Disabilities Administration (DDA) approves requests for
private duty nursing services for eligible clients on a case-by-case basis when
both of the following apply:
The application requirements listed under WAC 182-551-3300 are met.
The nursing care consultant determines the services to be medically necessary, as
defined in WAC 182-500-0070 and according to the process in WAC 182-501-
0165.
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Coverage
What is covered? (Refer to WAC 182-551-3000)
Upon approval, the Medically Intensive Children’s Program (MICP) manager will
notify the client’s Developmental Disabilities Administration (DDA) case manager
of the final determination. The MICP manager will authorize medically necessary
private duty nursing services up to a maximum of 16 hours per day (see
exception listed below), restricted to the least costly, equally effective amount of
care.
Exception: The MICP manager may authorize additional hours if
they are medically necessary. Additional hours beyond 16 per
day are subject to review as a limitation extension under WAC
182-501-0169.
The client’s DDA case manager will notify the client's caregivers. Once the specific
nursing agency is selected and prior to the initiation of care, that agency must
contact the MICP manager to obtain the authorization number and the number
of nursing care hours allowed for each MICP client.
Note: Before starting the care, call: MICP Manager, (360)
407-1504.
It is the nursing agency's responsibility to contact the MICP nursing coordinator
to obtain an authorization number and verify the total number of hours
authorized at the beginning of each approved time span. Additional nursing
hours beyond the allotted monthly hours must be prior authorized.
The MICP manager may adjust the number of authorized hours when the client’s
condition or situation changes. Any hours of nursing care services in excess of
those authorized by the MICP manager may be the financial responsibility of the
client, family, or guardian. Providers must follow the provisions of WAC 182-502-
0160 when billing the client.
The nursing notes and plan of care (see WAC 246-335-540) must be kept in the
client's file and made available for review by the MICP Manager upon request.
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Coverage Table
HCPCS
Procedure
Code
Appropriate
Modifier(s)
Appropriate
Modifier(s)
Appropriate
Modifier(s) Description of Services
T1000 TD RN, per 15 min.
T1000 TD TU RN, per 15 min., overtime
T1000 TD TV RN, per 15 min., holiday*
T1000 TD TK RN – second client; same home,
per 15 min.
T1000 TD TK TV RN – second client; same home,
per 15 min., holiday*
T1000 TE LPN, per 15 min.
T1000 TD TU LPN, per 15 min., overtime
T1000 TD TV LPN, per 15 min., holiday*
T1000 TD TK LPN – second client; same home,
per 15 min.
T1000 TD TK TV LPN – second client; same home,
per 15 min., holiday*
Effective March 1, 2020 (until further notice) – two temporary add-on procedure codes are
approved for Private Duty Nursing Services during the COVID-19 pandemic.
See the Apple Health (Medicaid) Private Duty Nursing Billing and Policy during COVID-19
pandemic (FAQ) for the temporary add-on procedure codes, modifier, and rates.
Key to Modifiers:
TD = RN
TE = LPN
TV = Holiday
TK = Second client
TU = Overtime
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Note: Procedure code T1000 requires prior authorization. HCA
pays for private duty nursing services per unit. 1 unit = 15
minutes.
Bill Your Usual and Customary Fee.
* Paid holidays are limited to: New Year's Day, Martin Luther King Day,
Presidents’ Day, Memorial Day, Independence Day, Labor Day, Veterans Day,
Thanksgiving Day, and Christmas Day.
Where can I find the fee schedule? See HCA’s Private duty nursing fee schedule webpage.
22 | PRIVATE DUTY NURSING FOR CHILDREN BILLING GUIDE
Billing
All claims must be submitted electronically to HCA, except under
limited circumstances. For more information, see HCA’s
ProviderOne Billing and Resource Guide webpage and scroll
down to Paperless billing at HCA. For providers approved to bill
paper claims, visit the same webpage and scroll down to Paper
Claim Billing Resource.
What are the general billing requirements? Providers must follow the ProviderOne billing and resource guide. These billing
requirements include, but are not limited to all of the following:
Time limits for submitting and resubmitting claims and adjustments
What fee to bill HCA for eligible clients
When providers may bill a client
How to bill for services provided to primary care case management (PCCM)
clients
Billing for clients eligible for both Medicare and Medicaid
Third-party liability
Record keeping requirements
May RN and LPN service hours be performed in
combination? Registered nurse (RN) service hours may be performed in combination with
licensed practical nurse (LPN) service hours. The combination must not exceed
the total hours that have been prior approved for each calendar month of care.
What about multiple clients in the same home? The Medically Intensive Home Care Program (MICHP) Manager may authorize
additional payment when the private duty nurse cares for more than one client in
the same home. Be sure to use a separate claim for each client receiving private
duty nursing services.
How do I bill services covering more than one month? If you receive prior authorization from the MICP Manager to provide more than
one month of services, bill each month on a separate line.
How do I bill claims electronically? Instructions on how to bill Direct Data Entry (DDE) claims can be found on HCA’s
Billers, providers, and partners webpage, under Webinars.
23 | PRIVATE DUTY NURSING FOR CHILDREN BILLING GUIDE
For information about billing Health Insurance Portability and Accountability Act
(HIPAA) Electronic Data Interchange (EDI) claims, see the ProviderOne 5010
companion guides on the HIPAA electronic data interchange (EDI) webpage.
The following claim instructions relate to private duty nursing services:
Name Entry
Place of Service These are the only appropriate codes
for this program:
Code Number – 12
To Be Used For - Home